La thérapie de resynchronisation cardiaque (CRT) est un traitement qui vise à rétablir le synchronisme de contraction du ventricule gauche chez les patients souffrant d’insuffisance cardiaque. Aujourd’hui encore, plus de 30% de ces patients ne répondent pas au traitement de resynchronisation. Afin de mieux comprendre les effets de la CRT sur la fonction cardiaque, un resynchronisateur biventriculaire a été implanté chez des chiens sains et des chiens atteints d’insuffisance cardiaque. Les fonctions ventriculaires gauche et droite ont été étudiées selon différents modes de resynchronisation. Les résultats de cette étude confirment premièrement que la durée du complexe QRS n’est pas un marqueur approprié dans l’optimisation de la CRT. Les résultats démontrent également qu’une optimisation individualisée de la CRT est nécessaire afin de maximiser l’effet de la thérapie sur le ventricule gauche et que la modulation du délai de resynchronisation a un impact significatif sur la fonction ventriculaire droite. Plus précisément, la fonction systolique du ventricule droit est optimale lors d’une activation précoce de l’électrode gauche. / Cardiac resynchronization therapy (CRT) was introduced to reestablish the synchronism in left ventricular of heart failure patients. At the present time, more than 30% of these patients do not respond to the resynchronization treatments. In order to better understand the effect of CRT on the cardiac function, a biventricular pacemaker was implanted in healthy dogs and in dogs with induced heart failure. Results from this study show that using the QRS duration in order to optimize CRT is not recommended. In addition, they confirm that an individualized optimization of the CRT is necessary to maximize the effect of the therapy on the left ventricle and that the modulation of the resynchronization delay has a significant impact on the right ventricular function. More precisely, right ventricular systolic function is optimal with an early activation of the left electrode.

Vinte e cinco pacientes com tempo de evolução pós-operatório médio de 10,6 ± 5,4 anos após a Operação de Jatene foram submetidos à avaliação da função ventricular esquerda pela ecocardiografia em repouso e durante o estresse farmacológico e à avaliação da circulação coronária pela cinecoronariografia e ultra-som intracoronário. O grupo apresentou função sistólica normal, alteração da função diastólica e reserva miocárdica reduzida. O estudo angiográfico, realizado em vinte e dois casos não revelou obstruções das artérias coronárias. Ao estudo ultra-sonográfico observou-se em todos, espessamento da camada íntima sugerindo processo de aterosclerose coronária precoce / Twenty-five patients underwent echocardiographic left ventricular function assessment at rest and during pharmacological stress and coronary circulation evaluation with coronary angiography and intracoronary ultrasound 10 ± 5,4 years after the arterial switch operation for transposition of the great arteries. Echocardiography revealed a normal left ventricular systolic function, impaired diastolic function and reduced myocardial reserve. No coronary obstruction was observed at angiography however intracoronary ultrasound showed intimal thickening in all, suggesting premature arterioscleroses

INTRODUÇÂO: Durante o desenvolvimento da hipertensão arterial sistêmica (HAS) ocorre a hiperatividade simpática, que está relacionada ao comprometimento dos sistemas baro e quimiorreflexo arteriais e disfunção ventricular esquerda (VE). Entretanto, a função ventricular direita (VD) tem sido pouco avaliada no contexto da HAS associada à desnervação sino-aórtica (DSA). OBJETIVO: Avaliar a função biventricular de forma não-invasiva e invasiva, a capacidade funcional, a sensibilidade barorreflexa e o controle autonômico cardiovascular em ratos Wistar (W) e ratos espontaneamente hipertensos (SHR) submetidos ou não à DSA. MÉTODOS: Após 10 semanas de DSA, a função cardíaca foi avaliada pelo teste de esforço (TE), ecocardiograma transtorácico e transesofágico, e a pressão diastólica final biventricular; as funções hemodinâmica e autonômica foram avaliadas pelo registro da pressão arterial (PA) e da freqüência cardíaca (FC), variabilidade da PA e da FC e sensibilidade barorreflexa. Os ratos (n = 32) foram divididos em 4 grupos: 16 W com (n = 8) e sem DSA (n = 8), 16 SHR com (n = 8) ou sem DSA (n = 8). RESULTADOS: A PA e a FC não apresentaram alterações entre os grupos DSA e não-DSA, entretanto, os SHR apresentaram níveis mais elevados da PA comparado com W. O TE mostrou que os SHR apresentaram melhor capacidade funcional em relação ao DSA e SHRDSA (W: 1,16±0,3m/s, DSA: 0,9±0,15m/s, *SHR: 1,46±0,29m/s, SHR-DSA: 1,02±0,31, *p< 0,05 vs. DSA e SHRDSA). Os SHRs apresentaram aumento da variabilidade da PA comparados aos W. Após a DSA houve aumento da variabilidade PA em todos os grupos comparados ao W (W: 15±29 mmHg2, *DSA: 49±27 mmHg2, *SHR: 60±29 mmHg2, *SHR-DSA: 137±76 mmHg2, *p<0,05 vs. W). Foi observado hipertrofia concêntrica do VE; disfunção sistólica segmentar e diastólica global do VE; disfunção sistólica global e segmentar, e diastólica global do VD; sinais indiretos de hipertensão arterial pulmonar pela ecocardiografia, mas evidentes no grupo SHRDSA. A pressão diastólica final do VD mostrou aumento em todos os grupos comparados com W (W: 3±0.39mmHg, *DSA:4,7±0,52mmHg, *SHR: 6;6±1.1mmHg, *SHRDSA: 7,8±0.87mmHg, *p< 0,05 vs. W), enquanto a pressão diastólica final do VE mostrou aumento dos grupos SHR e SHRDSA em relação ao W, e dos SHRDSA em relação aos DSA (W: 5,83±0,19 mmHg, DSA: 8,98±1,2 mmHg, *SHR: 12,51±4,73 mmHg, *#SHRDSA: 14,57±2.52 mmHg, *p< 0,05 vs. W, #p< 0,05 vs. DSA). Houve relação entre medidas não- invasivas e invasivas do VD, mostrando uma boa acurácia das medidas ecocardiográficas. CONCLUSÕES: Nossos resultados sugerem que a disfunção baroreflexa compromete a função biventricular. Além disso, os achados observados nos índices ecocardiográficos do VD indicam que a DAS pode induzir a elevação da pressão arterial pulmonar, reforçando o papel da disfunção barorreflexa na patogênese da doença cardíaca hipertensiva / INTRODUCTION: During the development of hypertension, sympathetic hyperactivity commonly seems to be related to the left ventricular (LV) dysfunction and baro and chemoreflexes impairment. However, right ventricle (RV) function has not been evaluated specially regarding the association of hypertension and baroreflex dysfunction. OBJECTIVE: To evaluate noninvasively and invasively the biventricular myocardial function, the functional capacity, the baroreflex sensitivity and the cardiovascular autonomic control in Wistar (W) rats and spontaneously hypertensive rats (SHR) submitted or not to sinoaortic denervation (SAD). METHODS: Ten weeks after DSA, cardiac function was evaluated by the maximal exercise test (MET), by transthoracic (TT) and transesophageal echocardiography (TEE) and the biventricular end diastolic pressures (EDP). Additionally, hemodynamic and autonomic functions were evaluated by the blood pressure (BP) and heart rate (HR) records, BP and HR variability and baroreflex sensitivity. The rats (n=32) were divided in 4 groups: 16 Wistar (W) with (n=8) or without SAD (n=8) and 16 SHR, with (n=8) or without SAD (n=8). RESULTS: Blood pressure and HR did not show any change between the groups SAD and without SAD, although, SHR showed higher BP levels in comparison to W. MET results showed that SHR had better functional capacity compared to SAD and SHRSAD (W: 1,16±0,3m/s, DSA: 0,9±0,15m/s, *SHR: 1,46±0,29m/s, SHR-DSA: 1,02±0,31, *p< 0.05 vs. SAD and SHRSAD). BP variability was increased in SHR groups compared to W. After SAD, BP variability increased in all groups compared to W (W: 15±29 mmHg2, *DSA: 49±27 mmHg2, *SHR: 60±29 mmHg2, *SHR-DSA: 137±76 mmHg2, *p<0.05 vs. W). Left ventricular concentric hypertrophy; segmental systolic dysfunction and global diastolic LV dysfunction; segmental and global systolic dysfunction, and global diastolic RV dysfunction; indirect signals of pulmonary arterial hypertension were shown by echocardiography, mostly evident in SHRSAD. The RV-EDP increased in all groups compared to W (W: 3±0.39mmHg, *SAD:4.7±0.52mmHg, *SHR: 6.6±1.1mmHg, *SHRSAD: 7.8±0.87mmHg, *p<0.05 vs. W), and the LV-EDP increased in SHR and SHRSAD groups compared to W, and in SHRSAD compared to SAD (W: 5,83±0,19 mmHg, SAD: 8.98±1.2 mmHg, *SHR: 12.51±4.73 mmHg, *#SHRSAD: 14.57±2.52 mmHg, *p<0.05 vs. W, #p<0.05 vs. DSA). There was a relation between invasive or noninvasive measurements of the RV showing good accuracy of echocardiographic measurements. CONCLUSIONS: Our results suggest that baroreflex dysfunction impaired biventricular function. Moreover, the findings of RV echocardiographic indices indicate that SAD may lead to increased pulmonary artery pressure, supporting a role for baroreflex dysfunction in the pathogenesis of the hypertensive cardiac disease

Estudou-se pela ecocardiografia em imagem fundamental, 30 pacientes no período pós-operatório de cirurgia cardíaca que encontravam se sob ventilação mecânica. Analisou-se o índice de escore de delineamento endocárdico (IEDE), a fração de ejeção do ventrículo esquerdo (FEVE) pelo método de estimativa visual, e os fluxos transvalvares pelo Doppler espectral e mapeamento de fluxo em cores antes e após a administração de um contraste ecocardiográfico a base de microbolhas. O IEDE passou de 1,53±0,63 para 2,01±0,56 após o uso do contraste (p < 0.001) e a FEVE pôde ser estimada em 27 de 30 exames após o uso do mesmo. Houve uma mudança na quantificação da insuficiência mitral em 5 exames, no gradiente de pico transvalvar aórtico em 1 paciente e no gradiente transvalvar de pico tricúspide em 8 pacientes / We studied by echocardiography in fundamental imaging (FI), thirty mechanically ventilated post cardiac surgery patients. LV endocardial border delineation score index (EBDSI), estimated left ventricular ejection fraction (LVEF) and color and spectral Doppler were analyzed before and after intravenous injection of ultrasound contrast. The use of contrast resulted in a significant increase in the number of well-delineated segments. EBDSI was 1.53±0.63, before contrast, increasing to 2.01±0.56 after it (p < 0.001). The LVEF could be evaluated in 27 of 30 exams after contrast. There was a change in the quantification of mitral regurgitation in 5 exams, in the aortic transvalvular peak gradient in 1 patient and measurement of peak flow velocity of tricuspid regurgitation in 8 patients

<p>Cilj: Svrha ovog istraživanja je da se odredi uticaj promena u funkciji, morfologiji i geometriji leve komore (LK) i odusustva očuvanog dnevno-noćnog profila krvnog pritiska (KP) na intrauterini zastoj u rastu fetusa (IUGR) i preterminsko zavr&scaron;avanje trudnoće kod gestacijske hipertenzije (GH), reverzibilnost tih promena posle porođaja i povezanost GH sa prisustvom arterijske hipertenzije u porodici. Metodologija: U ovu studiju, koja je koncipirana kao prospektivna, uključeno je 90 trudnica, 30 normotenzivnih, 30 sa GH i dipping profilom KP i 30 sa GH i non-dipping profilom KP. Svim ispitanicama urađen je kompletan dvo-dimenzionalni, pulsni i tkivni Doppler ehokardiografski pregled i ambulatorni 24-h monitoring KP u trećem trimestru trudnoće i 6 nedelja posle porođaja. Rezultati i diskusija: U grupi trudnica sa GH značajno vi&scaron;e su bili poremećeni parametri sistolne, dijastolne i globalne funkcije (EF, s&rsquo;, E, A, E/A, E/e&rsquo;, DTE, IVRT, IVCT, ET, Tei indeks, CO, CW, Ees), morfologije (IVSd, PLWd, RWT, masa miokarda, p&lt;0,0005) i geometrije LK (abnormalna geometrija 67,7% vs 3,3% kod normotenzivnih, p&lt;0,0005). Najizraženije promene bile su u podgrupi non-dippera. Posle porođaja registrovano je značajno popravljanje svih promenjenih ehokardiografskih parametara, a 96,7% ispitanica iz non-dipper podgrupe imale su očuvan dnevno-noćni ritam posle porođaja. U grupi sa GH utvrđeno je postojanje arterijske hipertenzije u porodici u 80% slučajeva u odnosu na 26,7% u kontrolnoj grupi (p&lt;0,0005). Analizom rezultata utvrđeno je da su povećanje maksimalne vrednosti noćnog dijastolnog KP, indeksa mase miokarda i totalne vaskularne rezistence nezavisni prediktori IUGR-a, dok su povećanje prosečne vrednosti noćnog sistolnog KP i indeksa mase miokarda i smanjenje EF nezavisni prediktori preterminskog porođaja. Zaključak: Promene u funkciji i morfologiji leve komore i non-dipping profil KP kod GH imaju prognostički uticaj na pojavu IUGR-a i preterminsko zavr&scaron;avanje trudnoće.</p> / <p>Objective: The purpose of this study was to determine the influence of changes in function, morphology, and geometry of the left ventricle (LV) and a non-dipping arterial blood pressure (BP) pattern on the intrauterine growth restriction (IUGR) and preterm delivery in pregnant women with gestational hypertension (GH), reversibility of these changes after delivery and connection between BP in family with GH. Methods: This prospective study included 90 pregnant women, 30 normotensive, 30 with GH and dipping BP pattern and 30 with GH and non-dipping BP pattern. All participants underwent a complete two-dimensional, pulsed and tissue Doppler echocardiography and 24-h ambulatory blood pressure monitoring in the third trimester and 6 weeks after delivery. Results and discussion: Participants with GH had more impaired parameters of the LV systolic, diastolic and global function (EF, s&rsquo;, E, A, E/A, E/e&rsquo;, DTE, IVRT, IVCT, ET, Tei index, CO, CW, Ees), morphology (IVSd, PLWd, RWT, myocardial mass, p&lt;0,0005) and geometry (abnormal geometry 67,7% vs 3,3% in normotensive, p&lt;0,0005). The greatest changes were noticed in non-dippers. All changed echocardiographic parameters became improved, while 96,7 % non-dipper participants became dipper after delivery. Arterial hypertension in family was present in 80% women with GH vs 26,7% in normotensive (p&lt;0,0005). Analyses revealed that maximum night-time diastolic BP, mass index and total vascular resistance were identified as independent predictors of IUGR. Average systolic night-time BP, mass index and EF were identified as independent predictors of preterm delivery. Conclusion: Changes in LV function, morphology and geometry and a non-dipping pattern of BP in GH predicts IUGR and preterm delivery.</p>

<p>Cilj: Cilj ovog istraživanja bio je da se utvrde promene koje arterijska hipertenzija dvojakim mehanizmima (dnevno-noćnim ritmom i svojim trajanjem) ostavlja na funkciju i geometriju leve pretkomore i komore srca. Ispitanici i metode: u ovo istraživanje bilo je uključeno 180 ispitanika koji su bili podeljeni u ispitivane grupe u odnosu na dnevno-noćni ritam arterijskog krvnog pritiska tokom 24-časovnog monitoringa arterijskog krvnog pritiska i to na sledeći način: grupa ispitanika sa očuvanim dnevno-noćnim ritmom arterijskog krvnog pritiska sastojala se od ukupno 90 ispitanika, a grupu onih sa naru&scaron;enim dnevno-noćnim ritmom arterijskog krvnog pritiska takođe je činilo 90 ispitanika. U svakoj od ovih grupa izvr&scaron;ena je dodatna podela ispitanika prema dužini trajanja arterijske hipertenzije na one kod kojih je arterijska hipertenzija trajala do 5 godina, one kod kojih je trajala od 5 do 10 godina i na one sa trajanjem arterijske hipertenzije vi&scaron;e od 10 godina. Svim ispitanicima rađen je incijalno 24-časovni ambulantni monitoring arterijskog krvnog pritiska, a nakon toga i ehokardiografski pregled radi određivanja parametara morfologije leve pretkomore i komore, kao i dijastolne funkcije leve komore. Rezultati i diskusija: nakon statističke obrade podataka dobijeni su rezultati koji ukazuju da se dijastolna disfunkcija stepena većeg od I statistički značajno če&scaron;će (p=0,011) uočava kod onih ispitanika koji nemaju očuvan dnevno-noćni ritam arterijskog krvnog pritiska. Naru&scaron;en dnevno-noćni ritam arterijskog krvnog pritiska takođe dovodi do povećanja indeksirane mase miokarda leve komore prema povr&scaron;ini tela ispitanika (LVM/BSA) &ndash; p=0,001; do zadebljanja zidova leve komore (IVS/PLW) &ndash; p=0,025, kao i do smanjenja sistolne brzine miokarda na nivou septalnog dela mitralnog anulusa (s&rsquo;) - p&lt;0,0005. Pored ovoga, u grupi onih sa naru&scaron;enim dnevno-noćnim ritmom arterijskog krvnog pritiska primećeno je če&scaron;će prisustvo ekscentrične hipertrofije miokarda leve komore (p=0,027). U odnosu na geometriju i funkciju leve pretkomore, naru&scaron;en dnevno-noćni ritam arterijskog krvnog pritiska dovodi do promena u smislu povećanja antero-posteriornog dijametra leve pretkomore (LA)-p=0,003; maksimalnog volumena leve pretkomore u komorskoj sistoli (LAVs) &ndash;p=0,007; indeksiranog LAVs prema povr&scaron;ini tela ispitanika (LAVs/BSA)-p&lt;,0005; E/e&rsquo; odnosa &ndash;p=0,040; rezervoarnog strain-a leve pretkomore (PLAS)- p=0,004; krutosti leve pretkomore (stiffness)-p=0,047, kao i brzine propagacije talasa kroz mitralni otvor (Vp)-p=0,029. Sa povećanjem dužine trajanja arterijske hipertenzije takođe su pokazane promene u morfologiji i funkciji leve pretkomore i leve komore srca. Dijastolna disfunkcija stepena većeg od I retko je bila uočena u grupi onih koji su arterijsku hipertenziju lečili kraće od 5 godina, a njeno prisustvo u ispitivanim grupama trajanja od 5 do 10 godina i duže od 10 godina bilo je statistički značajno če&scaron;će (p&lt;0,0005). Takođe, sa trajanjem arterijske hipertenzije statistički značajno se menjaju i parametri leve komore za koje smo pokazali da su pogor&scaron;ani kada dnevno-noćni ritam arterijskog krvnog pritiska nije očuvan, s tim &scaron;to smo ovde uočili i značajne promene u smislu postojanja lo&scaron;ijih vrednosti strain-a leve komore (LVGS)-p&lt;0,0005. Na sličan način kao i u odnosu na dnevno-noćni ritam arterijskog krvnog pritiska, menjao se predominantni oblik hipertrofije miokarda leve komore, te je uočeno značajno če&scaron;će (p=0,017) prisustvo ekscentrične hipertrofije kod ispitanika koji su duže lečili arterijsku hipertenziju. Uz ove promene, sa trajanjem arterijske hipertenzije, uočene su i promene sledećih ehokardiografskih parametara leve pretkomore (p&lt;0,0005): LA, LAVs, LAVs/BSA, E/e&rsquo;, PLAS, stiffness, Vp. Na kraju, formiran je i model za dijagnostiku dijastolne disfunkcije stepena većeg od I koji je testiran na 30 novih ispitanika i koji se pokazao kao kvalitetan uz visoku senzitivnost i specifičnost. Zaključak: arterijska hipertenzija dnevno-noćnim oscilacijama (ritmom), ali i svojim trajanjem dovodi do promena u funkciji i geometriji leve pretkomore i komore srca. Noviji ehokardiografski parametri (PLAS, LVGS, stiffness) su dobri pokazatelji ranih promena na nivou leve pretkomore i komore srca kod pacijenata sa arterijskom hipertenzijom.</p> / <p><!--[if gte mso 9]><xml> <o:DocumentProperties> <o:Author>Vukadin Milankov</o:Author> <o:Version>16.00</o:Version> </o:DocumentProperties> <o:OfficeDocumentSettings> <o:AllowPNG/> </o:OfficeDocumentSettings></xml><![endif]--><!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> 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Introdução: A doença valvar aórtica grave é caracterizada por um processo de acúmulo progressivo de fibrose intersticial no tecido miocárdico. No contexto da sobrecarga mecânica crônica do VE característica dessa condição, a quantidade de fibrose intersticial pode exercer um papel importante na indesejável transição entre hipertrofia ventricular esquerda compensada e insuficiência cardíaca congestiva clinicamente manifesta. Entretanto, a avaliação quantitativa da fibrose intersticial só tem sido possível através da análise histopatológica de fragmentos miocárdicos obtidos por biopsia endomiocárdica. Objetivos: Avaliar se a ressonância magnética (RM) cardíaca com técnica do realce tardio permite a quantificação não-invasiva da fibrose miocárdica quando comparada à análise histopatológica em pacientes portadores de doença valvar aórtica grave. Adicionalmente, avaliou-se a relação entre a quantidade de fibrose miocárdica e parâmetros prognósticos importantes, tais como mortalidade e recuperação funcional do VE após cirurgia de troca valvar aórtica. Métodos: Entre Maio de 2001 e Dezembro de 2003 foram incluídos 54 pacientes com indicação de cirurgia de troca valvar aórtica. Antes da cirurgia, todos os pacientes foram submetidos a RM cardíaca com técnicas de cine-RM e realce tardio miocárdico. A quantificação da fibrose miocárdica pela RM baseou-se na análise das imagens de realce tardio utilizando um novo algoritmo semi-automático. As regiões de fibrose miocárdica foram definidas como o somatório de todos os pixels do tecido miocárdico com intensidade de sinal acima de um limiar definido como: intensidade de sinal média do miocárdio + 2 desvios padrão da intensidade de sinal média da área remota + 2 desvios padrão da intensidade de sinal média do ar. Amostras de tecido miocárdico obtidas por miectomia durante o ato cirúrgico foram submetidas a coloração pelo picrosírius para quantificação da fibrose intersticial. Os pacientes foram submetidos a um segundo exame de RM cardíaca 6 meses após a cirurgia para se avaliar as alterações evolutivas dos parâmetros funcionais do VE e todos foram acompanhados por pelo menos 24 meses quanto à sobrevida após a cirurgia de troca valvar aórtica. Resultados: O percentual de fibrose miocárdica pela RM apresentou boa correlação com os valores obtidos pela histopatologia (r=0,69; y=3,10x+13,0; p<0,0001). A quantidade de fibrose miocárdica, tanto pela histopatologia como pela RM, apresentou correlação inversa significativa com a FE ventricular esquerda basal (r=-0,63 e -0,67 respectivamente; p<0,0001). Adicionalmente, o percentual de fibrose miocárdica apresentou correlação inversa significativa com o grau de recuperação funcional do VE após a cirurgia de troca valvar (r=- 0,42, p=0,04 para a histopatologia; r=-0,47, p=0,02 para a RM). Mais importante, a análise de Kaplan-Meier revelou que o acúmulo de fibrose miocárdica associou-se a menor sobrevida 52±17 meses após a cirurgia de troca valvar (teste log-rank: 2=6,32; p=0,01 para histopatologia; 2=5,85; p=0,02 para RM). Conclusões: A RM cardíaca permite quantificar as regiões de fibrose miocárdica com boa acurácia quando comparada à análise histopatológica nos pacientes portadores de doença valvar aórtica grave. A magnitude de acúmulo de fibrose miocárdica está associada a pior recuperação funcional do VE e a menor sobrevida após a cirurgia de troca valvar aórtica. / Introduction: Severe aortic valve disease is characterized by a process of progressive accumulation of interstitial fibrosis in the myocardial tissue. It has been shown that the amount of interstitial myocardial fibrosis can play an important role in the transition from well-compensated hypertrophy to overt heart failure in the setting of chronic left ventricular mechanical overload typical of this condition. However, assessment of interstitial myocardial fibrosis has only been possible through histological analyses of myocardial fragments obtained from endomyocardial biopsies, which is a complex and invasive procedure and, therefore, with limited clinical applicability. Objectives: Determine whether delayedenhancement cardiac magnetic resonance imaging (MRI) allows for the non-invasive quantification of myocardial fibrosis when compared against histopathological analyses in patients with severe aortic valve disease. Additionally, we evaluated the relationship between the amount of myocardial fibrosis and important prognostic parameters, such as all-cause mortality and LV functional recovery after aortic valve replacement. Methods: Fifty-four patients scheduled to undergo aortic valve replacement surgery were enrolled between May 2001 and December 2003. Before surgery, all patients underwent cine and delayedenhancement MRI in a 1.5 Tesla scanner. Quantification of myocardial fibrosis by cardiac MRI was based on the assessment of the delayed-enhancement dataset using a novel semiautomatic algorithm. The regions of myocardial fibrosis were defined as the sum of pixels with signal intensity above a threshold value defined as: mean signal intensity of the myocardium + 2 standard deviations of mean signal intensity of a remote area + 2 standard deviations of mean signal intensity of air. During open-heart surgery, myectomy samples were acquired from the LV septum and later stained with picrosirius for interstitial myocardial fibrosis quantification. A second cardiac MRI study was performed 6 months after surgery to assess long-term changes in LV functional parameters, and all patients were followed for at least 24 months to evaluate survival after aortic valve replacement. Results: There was a good correlation between the values of myocardial fibrosis measured by MRI and those obtained by histopathological analyses (r=0.69; y=3.10x+13.0; p<0.0001). The amount of myocardial fibrosis, either by MRI or by histopathology, exhibited a significant inverse correlation with LV ejection fraction before surgery (r=-0.63 e -0.67 respectively; p<0.0001). Additionally, the amount of myocardial fibrosis displayed a significant inverse correlation with the degree of LV functional recovery after aortic valve replacement (r=-0.42, p=0.04 for histopathology; r=-0.47, p=0.02 for MRI). Most importantly, Kaplan-Meier and Cox regression analyses revealed that higher degrees of myocardial fibrosis accumulation were associated with worse survival 52±17 months after aortic valve replacement surgery (log-rank test: 2=6.32; p=0.01 for histopathology; 2=5.85; p=0.02 for MRI). Conclusions: Cardiac MRI allows for the non-invasive quantification of myocardial fibrosis with good accuracy when compared with histopathological analyses in patients with severe aortic valve disease. The degree of myocardial fibrosis accumulation is associated with impaired LV functional recovery and worse survival after aortic valve replacement surgery.

Background: The ageing process not only increases the risk of coronary artery disease (CAD) but also complicates its diagnosis and treatment. It is therefore important to understand the newer concepts of cardiovascular ageing physiology as well as methods of predicting the outcomes of therapeutic options available for the elderly with severe CAD. Studies of atrioventricular (AV) ring or plane motion have attracted considerable interest in the last few years as a means of assessing ventricular and atrial function. As the displacement of AV rings towards the ventricular apex is a direct reflection of longitudinal fibre contraction, its measurement by echocardiography provides additional information regarding global and regional systolic and diastolic function. Left ventricular (LV) long axis amplitude of motion, referred to as mitral valve annular (MA) motion, is reduced in CAD and to some extent in the elderly as part of the normal ageing process. Objectives &amp; Methods: The aim of the present study was two-fold. First, to investigate the relationship between the timing of MA motion and transmitral and pulmonary venous flow in healthy subjects, and to define the physiological significance of that relationship including its potential diagnostic utility. Second, to investigate the relationship between the clinical outcome and the behaviour of long axis function in patients with severe ischaemic LV dysfunction (SLVD) after percutaneous coronary angioplasty (PTCA). Transmitral early (E) and late (A) filling, and pulmonary venous flow reversal (Ar) were studied by Doppler echocardiography, while at the left lateral AV ring, the MA motion in early (Em) and late (Am) diastole were recorded by Doppler tissue imaging (DTI) and M-mode echocardiography. Results: Healthy subjects – In early diastole the onsets of LV filling (E) and relaxation (Em) were simultaneous, and peak Em preceded peak E by 26 msec in all age groups, constituting a time interval referred to as early diastolic temporal discordance (EDTD). Similarly, the onsets of Am, A and Ar were simultaneous at onset and began approximately 84 msec after the electrocardiographic P wave. Peak Am preceded peak A by 23 msec in the young and by 13 msec in the elderly, a time interval referred to as late diastolic temporal discordance (LDTD). Peak Ar, on the other hand, coincided with peak Am in all age groups. With increasing age and sequential prolongation of isovolumic relaxation time, the peaks of Am, Ar and A converged. This point of convergence is described as atrial mechanical alignment (AMA). Patients – MA total amplitude of motion, rates of shortening and lengthening were all reduced in patients with SLVD. At mid-term, 3-6 months after PTCA, there was improvement in all these variables. A pre-procedure long axis cut off value of ≥5 mm was associated with favourable symptomatic outcome. Overall angiographic success was 95.2%, and event-free survival was 78.4% at one month and declined steadily to 62.3% at one year with 2.5% mortality. Conclusions: EDTD, which reflects ventricular restoring forces (suction) is age independent while the narrowing of LDTD leading to AMA provides a novel method to identify healthy subjects at increased dependency on left atrial contraction for late diastolic filling. Peak atrial contraction (Am) coincides with peak Ar, thus the timing of regional atrial contraction by DTI can be used to estimate corresponding measurements of Ar, which is often difficult to image by transthoracic echocardiography. In patients with SLVD long axis total amplitude of at least 5 mm at the left MA suggests a significant potential for segmental function recovery after PTCA. Keywords: Echocardiography, Doppler tissue imaging, ageing, coronary disease, left ventricular dysfunction, atrial contraction, electromechanical function, coronary angioplasty.

La thérapie de resynchronisation cardiaque (CRT) est un traitement qui vise à rétablir le synchronisme de contraction du ventricule gauche chez les patients souffrant d’insuffisance cardiaque. Aujourd’hui encore, plus de 30% de ces patients ne répondent pas au traitement de resynchronisation. Afin de mieux comprendre les effets de la CRT sur la fonction cardiaque, un resynchronisateur biventriculaire a été implanté chez des chiens sains et des chiens atteints d’insuffisance cardiaque. Les fonctions ventriculaires gauche et droite ont été étudiées selon différents modes de resynchronisation. Les résultats de cette étude confirment premièrement que la durée du complexe QRS n’est pas un marqueur approprié dans l’optimisation de la CRT. Les résultats démontrent également qu’une optimisation individualisée de la CRT est nécessaire afin de maximiser l’effet de la thérapie sur le ventricule gauche et que la modulation du délai de resynchronisation a un impact significatif sur la fonction ventriculaire droite. Plus précisément, la fonction systolique du ventricule droit est optimale lors d’une activation précoce de l’électrode gauche. / Cardiac resynchronization therapy (CRT) was introduced to reestablish the synchronism in left ventricular of heart failure patients. At the present time, more than 30% of these patients do not respond to the resynchronization treatments. In order to better understand the effect of CRT on the cardiac function, a biventricular pacemaker was implanted in healthy dogs and in dogs with induced heart failure. Results from this study show that using the QRS duration in order to optimize CRT is not recommended. In addition, they confirm that an individualized optimization of the CRT is necessary to maximize the effect of the therapy on the left ventricle and that the modulation of the resynchronization delay has a significant impact on the right ventricular function. More precisely, right ventricular systolic function is optimal with an early activation of the left electrode.

Estudou-se pela ecocardiografia em imagem fundamental, 30 pacientes no período pós-operatório de cirurgia cardíaca que encontravam se sob ventilação mecânica. Analisou-se o índice de escore de delineamento endocárdico (IEDE), a fração de ejeção do ventrículo esquerdo (FEVE) pelo método de estimativa visual, e os fluxos transvalvares pelo Doppler espectral e mapeamento de fluxo em cores antes e após a administração de um contraste ecocardiográfico a base de microbolhas. O IEDE passou de 1,53±0,63 para 2,01±0,56 após o uso do contraste (p < 0.001) e a FEVE pôde ser estimada em 27 de 30 exames após o uso do mesmo. Houve uma mudança na quantificação da insuficiência mitral em 5 exames, no gradiente de pico transvalvar aórtico em 1 paciente e no gradiente transvalvar de pico tricúspide em 8 pacientes / We studied by echocardiography in fundamental imaging (FI), thirty mechanically ventilated post cardiac surgery patients. LV endocardial border delineation score index (EBDSI), estimated left ventricular ejection fraction (LVEF) and color and spectral Doppler were analyzed before and after intravenous injection of ultrasound contrast. The use of contrast resulted in a significant increase in the number of well-delineated segments. EBDSI was 1.53±0.63, before contrast, increasing to 2.01±0.56 after it (p < 0.001). The LVEF could be evaluated in 27 of 30 exams after contrast. There was a change in the quantification of mitral regurgitation in 5 exams, in the aortic transvalvular peak gradient in 1 patient and measurement of peak flow velocity of tricuspid regurgitation in 8 patients